Basic Information
| Provider Information | |||||||||
| NPI: | 1013684349 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4515 PREMIER DR STE 307 | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272658356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022250 | ||||||||
| FaxNumber: | 3368813890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2021 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | HIGH | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT HEALTH SYSTEM | ||||||||
| AuthorizedOfficialTelephone: | 3367168021 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.